Costochondritis (Rib and Breastbone Cartilage Joint Problem)

It is not a condition that we often hear about although studies have shown that it may affect as much as 1 out of 10 people. Up to 30% of emergency room patients with chest pain have costochondritis (1994 study) and women tend to be more frequently affected. It is not serious although it can be very painful and will not lead to death. However, long term costochondritis can affect a person’s daily functioning in various ways.

What is costochondritis?

Costochondritis is a condition where the joints between the cartilages that connect the ribs to the breastbone (sternum) become inflamed. It may affect costosternal joints (between the costal cartilage and sternum joint) or the costchondral joint (between the costal cartilage and end of the ribs). Typically it presents with chest pain which can range from mild to severe. It is therefore not surpising that costochondritis is sometimes mistaken for cardiac (heart) pain.

Overall costochondritis is believed to be more common than is reported. Since the condition appears to be self-limiting in many instances it is often ignored and treated conservatively until it resolves. Costochondritis is a chronic condition and can persist for months, years and sometimes even for decades. There are no specific diagnostic investigations or treatments for costochondritis. It is usually diagnosed after excluding other possible causes of chest pain and treatment largely involves the use of anti-inflammatory drugs.

The Costal Cartilage and Joints

The costal cartilages are bars of cartilage that connect the ends of the ribs to the sternum (breastbone) at the front of the chest wall. The first seven pairs of costal cartilages (one pair on either side) connect directly to the sternum while the others communicate with the cartilages above it. The costal joints form where the cartilage interacts with the sternum or ribs. However, there is little to no movement at these joints but they contribute to the flexibility of the ribcage and front part of the chest wall.

Signs and Symptoms

The main symptom of costochondritis is chest pain. This pain is usually felt on the surface.  The intensity of the pain can vary considerably from one person to another. Sometimes pain is not present under normal circumstances but only strikes with certain movements and positions. For example, pain is typically not felt when breathing but may be triggered with a deep breath. Since the force in the arms is transferred to the ribcage, certain arm movements or actions like carrying heavy weights may also elicit pain.

Usually there are no other symptoms. Any swelling that may be present is minute and is not visible from the surface. Tenderness may be evident at varying degress of pressure. Inflmmatory symptoms like swelling, heat and redness are usually not present in costochondritis but is evident to some degree in a similar condition known as Tietze syndrome.  It is important to note that symptoms like dizziness, shortness of breath and sweating are not part of costochondritis and may instead be due to cardiac problems.

Causes of Costochondritis

The exact cause of costochondritis cannot always be clearly isolated. There is possibly an interplay of multiple factors along with repetitive strain and injury to the joints that eventually results in costochondritis. The ability of the rib cage to expand and contract is made possible in large part by these joints. Therefore any causes of repeated and forceful expansion and contraction of the chest can result in strain on the oints. This may be seen with violent bouts of coughing and vomiting.

Injury to the chest wall can also be a factor like with a severe impact with a steering wheel as is seen in a car accident or an assault with repeated blows to the chest wall. Since the force on the arms is transmitted to the rib cage, excessive activity with the arms can also be a contributing factor to costochondritis. It may be seen with lifting heavy weights but also with any repeated action of the arms particularly where the pectroal muscles are strained.

Other common joint conditions like rheumatoid arthritis may also have to be considered. People with fibromyalgia may also be prone althouh the pain could more likely be muscular than due to the costal joints. It has been noted that costochondritis is reported by some people with a vitamin D deficiency. As with many conditions, costochondritis may occur for unknown reasons and is therefore labeled as idiopathic.

Diagnosis of Costochondritis

There is no specific diagnostic investigation recommended for diagnosing costochondritis. X-rays and CT scans may be of limited use. Rther the approach to diagnosing costochondritis beyond the clinical presentation is to exclude other conditions that may present with similar symptoms. Therefore coronary artery disease, myocardial infarction (heart attack). pericarditis, pneumonia and other chest conditions need to be excluded by conducting relevant investigations for these conditions.

Treatment of Costochondritis

The treatment of costochondritis is largely dictated by the severity and duration of the condition. Generally costochondritis is a chronic condition unlike Tietze syndrome which is typically acute in nature. Mild cases of constochondritis can be managed conservatively to some extent by avoiding the triggers of the pain. It may resolve spontaneously in due course or require medication in severe cases or where it is persisting and affecting daily functioning.

The main drugs used in the treatment of costochondritis is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen and ibuprofen. Cortisone injections are reserved for severe cases. Muscle relaxants and ticyclic antidepressants are useful when there is muscle spasm or in the backdrop of fibromyalgia. None of these drugs can be considered to be a cure. Medical treatment may need to be repeated occasionally in the event of flareups. Rest, cold therapy and physical therapy may be helpful for long term management.

WARNING: Chest pain should always be investigated by a medical professional due to the seriousness of conditions like a heart attack. Even if there are no other symptoms like dizziness or difficulty breathing, and costochondritis seems like the most likely condition for the pain it is still imperative that a medical professional assesses the condition.

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